Implant-enhanced Removable Partial Denture Therapy · •Fixed partial denture (bridge) •Removable partial denture (RPD) *A fixed replacement is usually the preferred treatment

Implant- enhancedRemovable Partial Denture Therapy

Ting-Ling Chang, DDSClinical Professor

Division of Advanced ProsthodonticsUCLA School of Dentistry

2019 UCLA Hawaii Symposium

Treatment Options for Replacement of Missing Tooth/or Teeth

• No treatment• Implant supported restoration• Fixed partial denture (bridge)• Removable partial denture (RPD)

*A fixed replacement is usually the preferred treatment of choice.All treatments produced significant improvement in OHRQoL. The least amount of improvement was observed in patients with RDPs. OHRQoL changes in patients treated with FDPs and ISFPs were comparable. Swelem et al. Int J Prosthodont. 2014 Jul-Aug;27(4):338-47

RPD INDICATIONS

1. Long edentulous spans2. Absence of adequate periodontal support3. Structurally and anatomically compromised abutments4. Need for cross-arch stabilization5. Distal extension6. Need to restore soft and hard tissue contours7. Anterior esthetics8. Age and health9. Attitude and desires of pt.10.Ease of plaque removal

RPD INDICATIONS

1. Long edentulous spans2. Absence of adequate periodontal support3. Structurally and anatomically compromised abutments4. Need for cross-arch stabilization5. Distal extension6. Need to restore soft and hard tissue contours7. Anterior esthetics8. Age and health9. Attitude and desires of pt.10.Ease of plaque removal

2008

2011

The demand for RPD Therapy is increasing!

• Aging population• Economic considerations• Osseointegrated ImplantsiImproved versions of RPD’s that use implants for partial support United States

65 y/o or older: 13% in 2007 26% by 2030Europe 16% 27% by 2050Japan 23% 38% by 2050

The proportion of this group who are edentulous has also been steadily falling

The demand for RPD Therapy is increasing!• Aging population• Economic considerations• Osseointegrated ImplantsiImproved versions of RPD’s that use implants for partial support

The demand for RPD Therapy is increasing!• Aging population• Economic considerations• Osseointegrated ImplantsiImproved versions of RPD’s that use implants for partial support

Pt group that can benefit from the Implant RPD treatment option is largely untapped and has lots of potential to grow.

RPDoption

ImplantFixedoption

ImplantRPD

The bottom line:

RPD treatment is necessary because patients’ needs will remain and continue to grow. And implants are not likely to replace the needfor RPD because of high cost and

other factors.

Bassi et al, 1996

RPDoption

ImplantFixedoption

ImplantRPD

The bottom line:

RPD treatment is necessary because patients’ needs will remain and continue to grow. And implants are not likely to replace the needfor RPD because of high cost and

other factors.

Bassi et al, 1996

RPDoption

ImplantFixedoption

ImplantRPD

• The keys of a successful RPD design (with or without dental implants)

• Patient selection for implant-enhanced RPD therapy

• The goal of the implant-enhanced RPD treatment option:

esthetics versus comfort

• Treatment planning considerations: number and location of the implants,

selection of the attachment

Three Key Elements for Long-term Success in RPD Therapy

Support- Resistance to occlusal or vertical seating forces

Stability- Resistance to horizontal or torsional forces

Retention- Resistance to vertical dislodging forces

A RPD should be a well supported, stable, and retentive.

Five Parts of Well-Designed RPDsRestsMinor Connectors/Proximal PlatesMajor ConnectorsDenture Base ConnectorsRetainers

Design sequence

How to design a well supported, stable, and

retentive RPD?

Support-Resistance to occlusal or vertical seating forces

Of all three SSR support is the most importantbecause a well supported RPD can effectivelyprotect the remaining structures (teeth, mucosa, and underlying bone)

SUPPORT- Tooth vs. Mucosa

From:• Rests (tooth support)• Major connectors (mucosal support)• Denture bases (mucosal support)

Rests

The rest should direct functional forces in the long axis of the tooth.

To control the prosthesis in relationship to the teeth and supporting structures

To provide primary support for RPD

Acrylic partial with rests

Imagine a RPD with no rests…

Consequences:Loss of vertical controlRidge resorptionMal-adaptation

It becomes completely mucosal support

Irritated and traumatized soft tissue resulting from a RPD without positive rests

Lack of positive rests results in prosthesis displacement, which can destroy mucosa & periodontal attachment

Pt’s existing partial with no positive rest- 100% mucosal support

Positive RestA positive rest does not allow the prosthesis slide off the tooth or allow the tooth to move out of exiting relationship to other teeth as increased occlusal pressure is exerted.

Positive Circular Concave Rest Seat

Rest center is deeper than the surrounding area (spoon shape)

Ideal Locations for Rests

The teeth adjacent to the edentulous space

Additional teeth at the strategic position with excellent root morphology

Ideal bilateral distribution of RPD abutments

RPD abutment on one side onlySignificant RPD movement is anticipatedImplant should be considered to facilitate RPD therapy

Symmetrical and Equitable

SUPPORT- Tooth vs. Mucosa

From:• Rests (tooth support)• Major connectors (mucosal support)• Denture bases (mucosal support)

Primary Bearing Surface:TuberosityBuccal ShelvesRetromolar pad

Various major connectors providemucosal support from minimum tobroad coverage.

Single strap U-shape strap

AP palatal strapFull palatal coverage

SUPPORT- Tooth vs. Mucosa From:• Rests (tooth support)• Major connectors (mucosal support)• Denture bases (mucosal support)

StabilityResistance to horizontal or torsional forces

STABILITYRPD design parts enable the resistance to horizontal forces

From:• Proximal Plates• Bracing clasp arms• Lingual plates• Rests• Denture bases

Active I-bar

ReciprocationI-bar

Proximal Plates for Stability•Maintain arch integrity by anterior- posterior bracing action

Curvilinear parallel proximal plate

Two or more curvilinear proximal plates can provide side-to-side stability

RETENTIONRPD design parts enable the resistance to vertical dislodging forces

From:• Retainers/clasps • Proximal Plates on the RPD(guide planes on the tooth)• Indirect Retainers (for extension base RPD only)

Active Retainers for RetentionActive retainer (retainer that engages undercut to provide retention for the RPD)

--the remaining of the retainer is position at/or above the height of contour (except infra-bulge retainers)

-only the tip of the retainer is below the height of contour and engages the desired 0.01-0.02” undercut

Height of contour of the RPD abutment at a given path of insertion

Five Parts of Well-Designed RPDs

Rests (support from teeth)

Minor Connectors/Proximal Plates (stability)

Major Connectors (support from mucosa)

Denture Base ConnectorsRetainers (retention)

Design sequence

How to design a well supported, stable, and retentive RPD?

The RPD design principles remain the same for the implant-enhanced RPD therapy

Treatment Goals of RPD:

2. Organize interarch function( VDO, Occlusal Plane, Centric)and esthetics

1. Stabilize the individual arch and protect remaining structure

Biomechanical sound design for Implant-enhanced RPD therapy







Implant-enhanced RPD Therapy: Patient Selection

• Kennedy Class I and II ( UCLA extension-based RPD): To obtain a Kennedy Class III (UCLA Tooth-Borne RPD) configuration with

the help from implant(s)

This approach may not be easily achievable due to anatomic limitations

Kennedy I Kennedy II Kennedy III Kennedy IV

Candidates for Implant-enhanced RPD Therapy

• Kennedy Class I and II ( UCLA extension-based RPD) • Compromised RPD abutment distribution:

Lack of bilaterally positioned RPD abutment • Patients with prior unsatisfied RPD experience• Patients who are interested in less extensive tooth replacement treatment option

(surgically and/or financially)

Pt JC before-treatment FMX (8/5/2005)

Case 1: Mr. JC

Pt JCbefore FMX (8/5/2005)

XX X X

XXX

X X

Treatment Plan:1. Extraction of #3, 5, 14, 15, and 312. Maxillary immediate treatment partial3. Possible implant placement to improve the treatment outcomes of maxillary cast RPD4. Mandibular cast RPD or implants to replace #30 (and #31).

Case 1: Mr. JC

Maxillary RPD is a distal extension RPD

There will be an axis of rotationdefined by the two most distal rests

Case 1: Mr. JC

RPD Design Sequence:1. Rests

RPD Design Sequence:1.Rests2.Proximal plates/minor connector

RPD Design Sequence:1.Rests2.Proximal plates/minor connector3. Major connector

RPD Design Sequence:1.Rests2.Proximal plates/minor connector3. Major connector4. Denture base connector

RPD Design Sequence:1.Rests2.Proximal plates/minor connector3. Major connector4. Denture base connector5. Retainers

0.01”

0.01”

Choice of Major Connectors:

Anterior-posterior palatal strap

Support from the teeth:Number and the

periodontal status of the remaining teeth

Support from the mucosa+

= Sum of Support

Full palate coverage:Acrylic vs. Metal

Adding implant to:1. More even and equal distribution of RPD abutment for

support and stability2. Attachment(s) on implant(s) to provide retention and

eliminate retainer on #8- More optimal esthetic result

Number of implants needed (1, 2, or 3?)1. Biomechanical consideration to avoid

implant overloading2. Anatomic consideration3. Treatment cost 4. Available inter-arch space

Treatment Benefits of This Maxillary Implant-enhanced RPD

Three implants were recommended for this patient due tothe large palatal defect (decreased mucosal support)

Maxillary veneer graft

Two implants (4mm wide11.5 mm long) placedat #5 and 7 sites

Case 1: Mr. JC

Case 1: Mr. JC

RPD design without implants

November 2008

Pick-up Impression (Open Tray) at implant fixture level

5mm cuff height3mm cuff height

About ERA attachments…Micro ERA:20% smaller

Different cuff heights, compatiblewith major implant systems

7° tolerance Three additional5°,11°, and 17°angled attachments

0.5mm less vertical space and has a diameter of almost1.0mm less

About ERA attachments…Black = Processing MaleWhite = Light RetentionOrange = Moderate RetentionBlue = Heavy RetentionGrey = Very Heavy RetentionYellow = More retention than greyRed = The Most retentive

0.4 mm vertical resiliency

Case 1: Mr. JC

Rests prep on the existing PFMs

Case 1: Mr. JC

Case 1: Mr. JC

White-colored ERA plastic insert - the least retentive one

Case 1: Mr. JC

Case 1: Mr. JC

Case 1: Mr. JC

October 2010 (2+ year Follow UP)

Pt JK, 80 y/o male, presented for implant consultation for implant-supported FPD Medical history was significant for gout, DM II, CAD, MI, angioplasty/stent placement, CHF and Implantable Cardioverter Defribrillator (ICD) placement

Bilateral sinus lift and graft/implants to replacement 3, 4, 5, 6, 7, 12, 13, 14, and (#2/15)

Case 2: JK

#3 #4 #5 #6#3 site

#4 site #5 site #6 site

MaxillaryRight posteriorQuadrant CT Evaluation

Case 2: JK

#5#6

#5 site

#12 #13#14

#12

#13 #14

MaxillaryLeft posteriorQuadrant CT Evaluation

#13 and 14 sitesrevealed inadequate bonevolume and requiresinus graft

Case 2: JK

Due to complex medicalhistory, pt requested totake small steps for each surgery.

#8 was extracted and socket preservationwith Bio-Oss.

Case 2: JK

Maxillary Interim Partialto reevaluate patient’s perceived satisfaction toward to removable prosthesis

After 6-month pt was satisfied with the interim partial and the definitive pros plan was confirmedfor implant-assisted RPD No rests

100% mucosal support for reversible testing onImplant candidate

Case 2: JK

#4 site #5 site#12

NobelReplaceGroovy Implant4.3 mm by13 mm long

Case 2: JK

Nobel Replace Groovy Implants 4.3 mm by 13 mm long were placed at #4, 5, 12 sites

Case 2: JK

Case 2: JK

Positive rests#7: mesial circular concave rest#9: cingulum rest#11: cingulum rest

Design Principles forImplant-assisted RPDRestsMinor connectors/Proximal platesMajor connectorsDenture connectorsRetainers

Case 2: JK

Locator abutment

Case 2: JK

ImplantLocator Attachment

Order by soft tissue height in mm

www.preat.com/locimplant.htmwww.ZestAnchors.com

0-6 mm

http://www.preat.com/locimplant.htm

Final Impression for RPD frameworkImplant impression can be obtained with open tray impression copings at the implant fixture level during the RPD framework impression OR the altered cast impression procedure

Case 2: JK

Case 2: JK

Interarch Space Consideration

Case 2: JK

Implant positions were obtained at the fixture level during the altered cast impression (open tray impression coping)Indirect method (lab processing) for Locator attachments to reduce chair timeBlack locator pattern for processing

Replace with desirableretention locator pattern(Blue, the least retentive)

Case 2: JK

Implants are relatively Parallel to each other (up to20° between implants)

To overcome implant angulation issue

www.preat.com/locimplant.htmwww.ZestAnchors.com

http://www.preat.com/locimplant.htm

Implants’ angulations

Implant-enhanced RPD• Same Design Principles of RPD• Biomechanical Considerations of Implant(s) and Abutment teeth• Improve outcomes• More affordable option than implant fixed option

Case 2: JK

Case 3: Pt KB

Patient presented with fractured #21 and 22 splinted crowns at the subgingival level

#26-27 splinted crowns present no clinical mobility withgood margin integrity

Lack of RPD abutment at patient’s left quadrant presentschallenge for RPD (multiple axis of rotations on two abutments

Case 3: Pt KB

In clinical practice, mandibular distal extension RPDs receive a poor reputation among both dentists and patients. Patients’ appreciation is unpredictable and complaints include food retention underneath the saddle and pain, resulting from the inherited biomechanical disadvantages and the rotational movement under mastication. Patients discontinue wearing them or insist on replacement by a new one at a high rate.

The limitations of the md extension based RPD must be discussed and implant-enhanced RPD for mandibular extension based scenarios should be considered as an alternative option.

Extraction of retained roots #21 and 22Immediate implant placement

Case 3: Pt KB

Case 3: Pt KB

Case 3: Pt KB

Case 3: Pt KB

Case 3: Pt KB

Case 3: Pt KB

Follow up after 3+ years offunctional loading

Feb 21, 201710 years follow up

Case 3: Pt KB

Candidates for Implant-enhanced RPD Therapy

• Kennedy Class I and II ( UCLA extension-based RPD) • Compromised RPD abutment distribution:

Lack of bilaterally positioned RPD abutment • Patients with prior unsatisfied RPD experience• Patients who are interested in less extensive tooth replacement treatment option

(surgically and/or financially)

Long-term Implant Survival Rate in Implant-enhanced RPD

• 32 consecutive patients(mean age 56.8 years) with 64 Branemark (Mark III) implants. Follow-up ≥ 8 years

• Satisfaction, implant survival, and prosthetic success were evaluated• Kennedy classification (Class I = 19, Class II = 10, Class III = 3)• The implants primarily functioned as retention elements connected to the dentures with a

resilient ball attachment

Bortolini el al. Journal of Prosthodontics 20 (2011) 168–172

Patient Satisfaction (scale 1-5)

• Before 1 year after treatment1.31±0.43 4.59±0.47

• Caution!! All patients evaluated in this study presented requesting new prostheses because they were not satisfied with their current RPDs

• Patient satisfaction was improved with RPD/implant treatment but may be overestimated.


Implant and RPD Failure Rate

• The overall implant success was 93.75% (4/64 failures)• The overall prosthesis success of IR-RPD rehabilitation was 100%.• Periimplant soft tissues and residual edentulous ridges remain

stable over time• Bone resorption around the implants is within acceptable limits and

is comparable to that seen with standard implants.


Prosthetic Complications and Maintenance Over 8 Years of F/U

Loose abutment 2 cases in 2 patientsTooth substitution 29 times in 24 patients Relining 93 relinings in 32 patients

Resilient components were replaced annually


Other Characteristics of This Study

Implant positions

Implant position Maxilla Mandible Lateral incisor 1 0 Canine 21 10 First premolar 14 9 Second premolar 6 3

Implant sizes (Branemark MKIII) Implant size (mm) Number of implants

3.75 × 10 8 3.75 × 11.5 15 3.75 × 13 22 3.75 × 15 15 5× 10 2 5× 11.5 2

Majority of the implants were placed in the more anterior positions (outside the anatomic limitations)

All implants were 10 mm or longer


Take Home Message

For patients with concerns of traditional RPD treatment, implant-assisted RPD can improve patient’s satisfaction and offers comparable high implant survival rate and stable peri-implant condition after 8 years of follow-up.








What do we want to accomplish with implant(s) to enhance the outcomes of RPD therapy?

Esthetics or Comfort?Patient expectation and preference?

Jensen et al. Clin Implant Dent Relat Res. 2017Clinical Oral Implant Research 2016J of Dentistry 2016

NoteworthyProspective comparison study, cross-over randomized trial


Molar (M) implant:4.1 mm x 6 mm

Premolar (PM) implant:3.3 mm x 8 mm

Edentulous Maxilla

Locator attachment

Straumann Implant System

Implant RPD

• Prospective comparison study, cross-over randomized trial• 30 subjects: upper edentulous, lower partial edentulous (Kennedy class I)• Implants placed at the premolar and molar regions• Mandibular bilateral distal extension RPD w/o implants,

with premolar implants only, and with molar implants only. 3 months to test each implant position.

• Use Locator attachmentJensen et al. Clin Implant Dent Relat Res. 2017

Clinical Oral Implant Research 2016J of Dentistry 2016

RandomizedProspectiveCross-over (comparison) clinical trial

Study Design• Number of implant(s): one on each quadrant• How implants used: resilient Locator attachment • Size/Length: Premolar site 3.3 x 8 mm Molar site 4.1 x 6 mm• Patient-centered subjective outcomes: OHIP-NL49 , contentment assessment

on a Visual Analogue Scale• Objective outcomes: chewing ability test ( Mixing Ability Index, MAI), number

of hrs wearing the prosthesis• Pt preferred implant position: premolar or molar site


The lower the OHIP score is, indicate less disease-related disruptive impairment.The Oral Health Impact Profile (OHIP) questionnaire - a sophisticated and well validated instrument for assessment of OHRQoL .

OHIP

Subjective Evaluation: OHIP

•Copy and paste J Dentistry table 2


In the present study of patients with apoorly functioning bilateral free-ending mandibular RPD, solelyproviding a new RPD proved also being effective.

The addition of implant significantly improved overall quality of the RPD and pt satisfaction

Objective Evaluation

• Masticatory performance was studied by means of a mixing ability test.

Jensen et al. Clin Implant Dent Relat Res. 2017

15 chewing strokes

Pristine wax tablet for the mixing ability test

Mixed tablet and flattened after 15 chewing strokes

Objective Evaluation

• Masticatory performance was studied by means of a mixing ability test. The flattened wax is then photographed and analyzed A lower Mixing Ability Index (MAI) score implies a better mixed tablet, hence better masticatory performance.

Jensen et al. Clin Implant Dent Relat Res. 2017

Objective Evaluation • Masticatory performance was studied by MAI

• Masticatory performance as expressed by the MAI did not change significantly after a new RPD• Masticatory performance was statistically significant improved with implant support, to a level than

prior to treatment and after provision of a new, unsupported RPD. The MAI was comparable to dentate patient group (18.3).

• The implant position, M or PM, had no significant effect on masticatory performanceJensen et al. Clin Implant Dent Relat Res. 2017

Jensen et al.J of Dentistry 2016 55:92-98

The data suggest that patients’ expectations of contentment with an ISRPD were met since no significant difference was seen between expected and actually achieved contentment.

This is seen as an important indicator of the quality of treatment. It enhances the reputation of the health care provider and implant dentistry in general. It transforms new patients into loyal customers and brings new referrals by ‘word of mouth’.

Implant RPD: Patient Expectations

New RPD

Pt expectationsImplant RPD

Old RPD

Take Home Message

• Mandibular implant support favorably influences oral health related patient-based outcome measures in patients with a bilateral free-ending situation.

• The majority of patients prefer the implant support to be in the molar region.Patient Characteristics:Upper edentulous, lower partial edentulous (Kenney I)Mean age : 60.9 y/oShorter implants: pm site 3.3x 8 mm, molar site 4.1 x 6 mm


• Implant-retained partial overdentures with resilient attachments are a predictable and cost-effective treatment option for partially edentulous patients.

• When implant is placed to the more distal position which is preferred position based on the OHIP-NL49, an anterior clasp/retainer can not be avoided with esthetic consequences. (pre-treatment informed consent: esthetics versus comfort)

• Published literatures reported comparable high implant success rate and increasing patient satisfaction for removable partial denture associated with implants in the extension-based situations.

Take Home Message

Long-term success of implants depends on

biomechanical equilibrium

ImplantBiomechanics

LOAD BEARING CAPACITY1. Quality of bone site 2. Quality of bone implant interface3. Implant microsurfaces

Machined vs. rough surfaces4.Implant

Number and Arrangement Linear vs. Curvilinear

Length and diameterAngulation

ANTICIPATED LOAD1. Occlusal factors

Cusp anglesWidth of occlusal tableGuidance type

Anterior guidanceGroup function

2. Cantilever forces Connection to natural dentitionSize of occlusal tableCantilevered prostheses

3. Parafunctional habits (bruxism)

4. Brachycephalics

Biomechanics Equilibrium>=

Pt AB, 52 y/o male, maxillary partialdentate, 6 implants placed

Case 4: AB

Pt AB, 4 out of 6 maxillary implants failed to osseointegration

Case 4: AB

Fixture level pick up impressionLabially angled implant angulation was noted

Case 4: AB

Implant Biomechanics

LOAD BEARING CAPACITY1. Quality of bone site ? 2. Quality of bone implant interface?3. Implant microsurfaces4. Implant

Number (fewer than tx plan) and arrangement

Linear vs. CurvilinearLength and diameterAngulation (labial angled)

ANTICIPATED LOAD1. Occlusal factors2. Cantilever forces3. Parafunctional habits

(bruxism)4. Brachycephalics

For Pt AB

Implant Biomechanics

LOAD BEARING CAPACITY1. Quality of bone site ? 2. Quality of bone implant interface?3. Implant microsurfaces4. Implant

Number (fewer than tx plan) and arrangement

Linear vs. CurvilinearLength and diameterAngulation (labial angled)

5. Tooth support6. Mucosal support

ANTICIPATED LOAD1. Occlusal factors2. Cantilever forces3. Parafunctional habits

(bruxism)4. Brachycephalics5. Use implants mainly for retention

Biomechanics Equilibrium

For Pt AB

#8 and 9 splinted together with two ERA AttachmentsERA attachment impression housings were picked up at #8 and 9 sites at the same time of implant final impression

Case 4: AB

Case 4: AB

Two custom ERA Attachments on the implants were made1. Correct the labial angulation2. Follow the path of insertion

with the two ERAs of #8 & 9

Case 4: AB

Implant Prosthesis Design Concept

3. Implants are mainly designed for retention (from ERAs). Support and stability are mainly from teeth and mucosa

1.Implants’ labially inclined angulation were corrected by custom abutment with ERA plastic patterns

2. Due to the failure history of the other 4 implants, maximize the support by positive rests on #2, 8, 9, 14 and palatal major connector coverage

4. #8 and 9 are splinted and ERAs are designed to maximize theesthetics

Case 4: AB

Case 4: AB

White-colored (the least amountof retention) ERA were used on the implants.

Blue-colored (higher retention) ERA were used on the teeth #8/9

Case 4: AB

Case 4: AB

Case 4: AB

Lessons Learned from Pt AB

• Despite the best effort implants sometimes still fail. Prosthodontic contingency plan needs to be discussed during the consult.

• Fewer implants with poor angulation• Support, stability, and retention• Turn a compromised biomechanics situation around to a esthetic treatment

outcome with good long-term prognosis

Case 4: AB

Pt IR Panoramic

Case 5: IR

Pt IR 1990 Panoramic after removal of failed blade implant and hopeless teeth

Case 5: IR

Pt IR 1991 Panoramic after placement of 5 implants to restore the partially dentate mandible

Case 5: IR

Pt IR 1996 Panoramic

Case 5: IR

Pt IR 2003 FMX12 y/o functional loading on the mandibular implants

Case 5: IR

2-implant tissue bar with one ERA attachment to provide retention, improved stability, and improved support for the upper right quadrant

Positive rests on #2 and 5Active I-bar (0.01” retention) on #2 Passive I-bar on # 5 for bracing/stability

Long-term Success in Implant-enhanced RPD Therapy: RPD Design Principles and Implant Biomechanical Equilibrium

Case 5: IR

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Documents

Implant-enhanced Removable Partial Denture Therapy · •Fixed partial denture (bridge) •Removable partial denture (RPD) *A fixed replacement is usually the preferred treatment